Optimal Use of Imaging in Rheumatoid Arthritis
The fields of rheumatology and radiology are changing rapidly. Potential roles for imaging in rheumatoid arthritis (RA) include assisting in early detection and/or diagnosis, prognosticating future RA aggressiveness, and assessing disease activity in real time. While there are good data for some of these applications, others require more research.
Professor of Medicine
“There are numerous potential opportunities for using MRI and ultrasound. These modalities are certainly helpful in identifying inflammatory arthritis in patients when the diagnosis is clinically uncertain, but the value of imaging in ongoing patient management is less clear.”
There are many more options for imaging than ever before; in some cases, there are good data on the value of its use, but more data are needed in other areas. Early in the course of the disease, functional issues are often driven by inflammation, but, as time goes on, particularly in untreated or undertreated patients with RA, it is the damage itself that begins to drive the functional deficits. And even if you reduce the inflammation, you are left with those challenges. Thus, one of the main purposes of imaging is to ensure that we pick up on the signs that structural damage is starting to occur so that we can intervene in this process. By initiating aggressive therapy early, structural and functional abnormalities can often be avoided.
There are numerous potential opportunities for using magnetic resonance imaging (MRI) and ultrasound. These modalities are certainly helpful in identifying inflammatory arthritis in patients when the diagnosis is clinically uncertain, but the value of imaging in ongoing patient management is less clear. The advantages of MRI and ultrasound are that you can identify structural changes earlier than on x-ray and you can detect inflammatory changes that would not be seen on x-ray. There is much research on the use of MRI to identify synovitis and early changes that may not be detected on x-ray. However, the challenge is that not all of these early changes proceed to radiographic abnormalities. Additionally, it is unknown to what extent the detection of subclinical changes is helpful in our current approach. That is, in the treat-to-target paradigm, the assessment of disease activity is largely clinical—not imaging based—and recent studies have found that the addition of MRI or ultrasound does not add much value in achieving therapeutic targets. Another question is whether following imaging parameters over time is useful. In the era of biologics, there is little progression of radiographic damage, so the value of serial imaging is diminished. The other challenge is that, even if some progression is detected, it is unclear which treatment we could switch that patient to that would be better. Another possible use of ultrasound is for identifying patients who are candidates for treatment tapering or discontinuation. You might be more comfortable about withdrawing or tapering therapy in a patient with RA who is not only in remission clinically, but on ultrasound as well. A final area in research is the use of imaging to more rapidly identify response—or nonresponse—to therapy, possibly by identifying patients who have rapid resolution of findings vs those who have persistent findings on ultrasound. There are not a lot of data in this area, but it is important and it certainly has a theoretical rationale.
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